DESCRIPTION: (provided by the applicant) Long-term mechanical ventilation (LTMV) occurs up to 20 percent of patients who require mechanical ventilation. LTMV is invasive, expensive and associated with high risk of serious complications and increased mortality. A superior weaning technique or ventilator mode for LTVM patients has not been identified. And it has, therefore, been proposed that the technique or ventilator mode for LTVM patients has not been identified. And it has, therefore, been proposed that the manner or process in which a particular mode of weaning is applied may have greater impact on weaning success than the mode itself. The aim of this sub study is to provide an in-depth description and analysis of the process of care during weaning from LTMV. Specifically, this study will describe 1) interpersonal interactions (communication contacts, extent and content of communications), 2) therapeutic strategies (e.g., medications/nutrients, use of instruction or comfort measures, rehabilitative treatments), and 3) social (patient, family, clinician characteristics) and environmental factors that contribute to weaning success or are associated with inconsistent/plateau weaning from LTMV. This proposal will establish a complementary sub study to a clinical trial (R01-NR05204) currently in progress that tests an acute care nurse practitioner intervention to improve weaning from LTMV in step-down ICU. The descriptive exploratory design will use focused observation of weaning events in 30 cases, longitudinal description of those cases, and interviews with patients, clinicians, and family members to be conducted during the final 14-months of data collection in the parent study. Longitudinal case description will permit the recording and analysis of repetition and variation in communication and care strategies related to ventilator weaning. Analysis techniques will include leveled coding, constant comparison within and between cases, and matrix formation. In collaboration with the parent study, we will be able to link physiological data with detailed description of interpersonal interactions, therapeutic strategies, and social and/or environmental factors in current practice that contribute to weaning progress and success (or inconsistent/plateau weaning patterns). This sub study proposes to capitalize on a unique "natural laboratory" to fill important gaps in our understanding of advanced specialty clinician practice (acute care nurse practitioner practice and the practice of ICU physicians) so that interventions can be standardized and tested for application in both advanced practice nurse and physician models of care. The proposed sub-study will use an innovative triangulation of data and methods complementing the parent study to provide clarification explanation, and elaboration of parent study findings as well as independent findings of critical importance to the care of LTMV patients.